“Nobody can go back and start a new beginning, but anyone can start today and make a new ending.” ~ Maria Robinson
Polycystic ovary syndrome (PCOS)
1 out of 10 women has PCOS.
PCOS Care Center: Team Approach,
Working Together for the Best Outcome
Because of her special interest in diagnosing PCOS early, near onset of puberty when possible, Dr. Malley is in the process of developing a center for PCOS patients, where they can receive state-or-the-art care, and the education necessary so that her patients receive the best management options, specifically tailored to their needs.
At the heart of the PCOS center, Dr. Malley will help navigate and her PCOS patients through a multidisciplinary team approach with a talented group of dedicated specialists, including a medical endocrinologist, dermatologist, nutritionist, therapist, and exercise regimen to address and anticipate concerns before they become a problem. We will also include your pediatrician in all recommenations.
PCOS affects women of all races and ethnic backgrounds. Symptoms most often appear in the teen years, but some women do not have symptoms until they are in their early to mid-20’s.
Recently PCOS has been associated with future risk of:
- hypertension
- hyperlipidemia
- insulin resistance
- metabolic syndrome
- hypothyroidsim
- endometrial cancer
- fertility problems
Some studies have shown women with irregular menstrual cycles are more likely to develop coronary artery disease at younger ages than women with regular cycles, even if the women were not identified as having PCOS.
Signs of PCOS?
Teen girls & young women with PCOS have common signs including:
- Irregular periods that come every few months, or too often
- Extra hair on your face or other parts of your body, called "hirsutism"
- Hair loss or male-pattern thinning
- Acne, oily skin
- Weight gain and/or trouble losing weight
- Patches of dark skin on the back of your neck and other areas: dark soft skin on back of neck, elbows, knees, underarms, between breasts, across knuckles and groin, called "acanthosis nigricans".
- Depression
PCOS is a condition that causes irregular menstrual periods and elevated levels of androgens (male hormones) in women. The elevated androgen levels can cause excessive facial hair growth, acne, and/or male-pattern hair thinning.
Although PCOS is not completely reversible, there are a number of treatments that can reduce symptoms. Most women with PCOS lead normal lives without significant complications.
PCOS Cause
The cause of PCOS is not completely understood. PCOS is thought to be caused by an imbalance in the hormones (chemical messengers) in your brain and your ovaries. Many girls also have higher than normal levels of insulin from the pancreas.
PCOS usually happens when a hormone called LH or levels of insulin are too high, which results in extra testosterone production by the ovary. It is believed that abnormal levels of the pituitary hormone LH and high levels of male hormones (like testosterone and other androgens) interfere with normal function of the ovaries.
Normal menstrual cycle
The brain (including the pituitary gland), ovaries, and uterus normally follow a sequence of events once per month; this sequence helps to prepare the body for pregnancy.
Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH), are made by the pituitary gland. Two other hormones, progesterone and estrogen, are made by the ovaries.
During the first half of the cycle, small increases in FSH stimulate the ovary to develop a follicle (cyst) that contains an egg (oocyte). The follicle produces rising levels of estrogen, which cause the lining of the uterus to thicken and the pituitary to release a very large amount of LH. This midcycle "surge" of LH causes the egg to be released from the ovary ("ovulation".) After, the ovary produces estrogen & progesterone to prepare the uterus for possible implantation/pregnancy.
Menstrual cycle in Young Women With PCOS
In women with PCOS, multiple follicles (cysts) may develop. On ultrasound they are sometimes referred to as "a string of pearls" as they are all similarly sized. The follicles are unable to grow to a size that would trigger ovulation. (See ovarian ultrasound at left, no dominant follicle preparing to ovulate = "polycystic ovaries".)
Therefore, small follicles (4 to 9 mm in diameter) accumulate in the ovary. None of these small follicles are capable of triggering ovulation. As a result, the levels of estrogen, progesterone, LH, and FSH become imbalanced.
Androgens (male-type hormones) are normally produced by the ovaries, the adrenal gland, and other sources. Examples of androgens include testosterone, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEA-S).
Androgens may become increased in women with PCOS because of the high levels of LH, but also because of high levels of insulin that are usually seen with PCOS.
PCOS Symptoms
The changes in hormone levels, described above, cause the classic symptoms of PCOS:
- absent or irregular menstrual periods
- abnormal hair growth or loss
- acne
- weight gain
- difficulty becoming pregnant
Signs and symptoms of PCOS usually begin around the time of puberty, although some women do not develop symptoms until adulthood. Because hormonal changes vary from one woman to another, patients with PCOS may have mild to severe acne, facial hair growth, or scalp hair loss.
Menstrual irregularity
If ovulation does not occur, the lining of the uterus (called the endometrium) does not uniformly shed and regrow as in a normal menstrual cycle. Instead, the endometrium becomes thicker and may shed irregularly, which can result in heavy and/or prolonged bleeding. Irregular or absent menstrual periods can increase a woman's risk of endometrial overgrowth (called endometrial hyperplasia), which in some cases can develop into endometrial cancer, over time.
Women with PCOS usually have fewer than six to eight menstrual periods per year. Some women have normal cycles during puberty, which may become irregular if the woman becomes overweight.
Dark Patches - Many adolescents with PCOS have higher levels of the hormone insulin in their blood. Higher levels of insulin can sometimes cause patches of darkened skin on the back of your neck, under your arms, and in your groin area (inside upper thighs). These velvety patches are called "acanthosis nigricans" and are seen in patients with increased risk of insulin resistance.
Weight gain and obesity — PCOS is associated with gradual weight gain and obesity in about one-half of women. For some women with PCOS, obesity develops at the time of puberty. In slim patients with PCOS, it is harder to maintain their weight than in their non-PCOS friends.
Hair growth and acne — Male-pattern hair growth (hirsutism) may be seen on the chin, neck, sideburn area, chest, and upper abdomen. Acne is a skin condition that causes oily skin and blockages in hair follicles, leading to pimples.
Acne and extra hair on your face and body can happen if your body is making too much testosterone. All women make testosterone, but if you have PCOS, your ovaries make a little bit more testosterone than they are supposed to. Skin cells and hair follicles are extremely sensitive to the small increases in testosterone found in young women with PCOS.
Insulin abnormalities
PCOS is associated with elevated levels of insulin in the blood. Insulin is a hormone that is produced by specialized cells within the pancreas; insulin regulates blood glucose levels. When blood glucose levels rise (after eating, for example), these cells produce insulin to help the body use glucose for energy.
- If glucose levels do not respond to normal levels of insulin, the pancreas produces more insulin. Excess production of insulin is called hyperinsulinemia.
- When increased levels of insulin are required to maintain normal glucose levels, a person is said to be "insulin resistant."
- When the blood glucose levels are not completely controlled, even with increased amounts of insulin, the person is said to have impaired glucose tolerance.
- If blood glucose levels continue to rise despite increased insulin levels, the person is said to have type 2 diabetes.
These conditions are diagnosed with blood tests, including the glucose challenge. Insulin resistance and hyperinsulinemia can occur in both normal-weight and overweight women with PCOS.
Risk of Diabetes in PCOS
Among women with PCOS, up to 35% of obese women develop impaired glucose tolerance by age 40, while up to 10% of obese women develop type 2 diabetes. The risk of these conditions is much higher in women with PCOS compared to women without PCOS.
Fertility Problems
Women with PCOS have a normal uterus and healthy eggs. Many women with PCOS may have trouble getting pregnant, but some women have no trouble at all. If you are concerned about your fertility (ability to get pregnant) in the future, talk to one of us about all the new options available, including medications to lower your insulin levels or to help you ovulate each month.
Heart disease Women who are obese and who also have insulin resistance or diabetes have an increased risk of coronary artery disease, the narrowing of the arteries that supply blood to the heart. Weight loss, daily exercise and treatment of insulin abnormalities can decrease this risk. Other treatments (eg, cholesterol lowering medications, treatments for high blood pressure) may also be recommended as you get older.
Sleep apnea
Sleep apnea is a condition that causes brief spells where breathing stops (apnea) during sleep. Patients with this problem often experience fatigue and daytime sleepiness. In addition, there is evidence that people with untreated sleep apnea have an increased risk of cardiovascular problems such as high blood pressure, heart attack, abnormal heart rhythms, or stroke. This risk may be changes in heart rate and blood pressure that occur during sleep.
Sleep apnea may occur in up to 30 percent of women with PCOS. The condition can be diagnosed with a sleep study, and several treatments are available.
PCOS DIAGNOSIS
There is no single test for diagnosing PCOS. It is often a clinical diagnosis based on history of infrequent menses with no other cause, in the setting of a young woman with excess hair growth and/or acne.
You may be diagnosed with PCOS based upon your symptoms, blood tests and pelvic sonogram of your ovaries. Expert groups have determined that a woman must have all of the following to be diagnosed with PCOS:
- Irregular menstrual periods caused by anovulation or irregular ovulation
- Evidence of elevated androgen levels. The evidence can be based upon signs (excess hair growth, acne, or male pattern balding) or blood tests (high androgen levels)
- No other cause of elevated androgen levels or irregular periods (eg, congenital adrenal hyperplasia, androgen-secreting tumors, or hyperprolactinemia)
Blood tests are usually recommended to determine if another condition is the cause of your signs and/or symptoms. Blood tests for pregnancy, prolactin level, thyroid stimulating hormone (TSH), and follicle stimulating hormone (FSH) may be recommended.
If PCOS is confirmed, the blood glucose and cholesterol testing are usually performed. In women with moderate to severe hirsutism (excess hair growth), blood tests for testosterone and DHEA-S may also be done.
All women who are diagnosed with PCOS should be monitored by a central physician overseeing their syndrome over time, this can be their adolescent gynecologist, pediatrician, internist or endocrinologist. Symptoms of PCOS may seem minor and annoying and treatment may seem unnecessary. However, untreated PCOS can increase a woman's risk of serious, preventable, chronic health problems over time.
PCOS TREATMENTS
The most common form of treatment for PCOS is the birth control pill; however, other kinds of hormonal therapy may include the "vaginal ring" and "the patch". Even if you are not sexually active, we may prescribe birth control pills because they contain the hormones that your body needs to treat your PCOS. By taking the birth control pill either continuously or in cycles you can:
- Correct the hormone imbalance
- Lower the level of testosterone (which will improve acne and lessen hair growth)
- Regulate your menstrual periods
- Lower the risk of endometrial cancer (which is slightly higher in young women who don't ovulate regularly)
- Prevent an unplanned pregnancy if you are sexually active
- Keep weight, blood sugar, cholesterol under control for life!
Oral contraceptives (OCPs): the most commonly used treatment for regulating menstrual periods in women with PCOS. OCs protect the woman from endometrial (uterine) cancer or overgrowth by inducing a monthly menstrual period. OCs are also effective for treating hirsutism and acne.
Women with PCOS occasionally ovulate, and oral contraceptives are useful in providing protection from pregnancy. Although an OC allows for bleeding once per month, this does not mean that the PCOS is "cured"; irregular cycles generally return when the OC is stopped. Oral contraceptives decrease the body's production of androgens, and anti-androgen drugs (such as spironolactone) decrease the effect of androgens.
These treatments can be used in combination to reduce and slow hair growth. Oral contraceptives and anti-androgens can also reduce acne. Other prescription skin treatments (eg, medicated lotions) or oral antibiotics may be recommended in some cases.
Side effects — Some women who take birth control pills stop having monthly bleeding or develop irregular spotting and bleeding. Irregular bleeding usually resolves after a few menstrual cycles.
- Weight gain? Many women worry about gaining weight on the pill. This doesn't usually happen with the currently available low-dose pills. Some women develop nausea, breast tenderness, and bloating after beginning the pill, but these symptoms usually resolve within 2 months.
- The pill is safe and effective, although it slightly increases the risk of blood clots in the legs or lungs; this is a rare complication in young, healthy women who do not smoke. The risk is higher in women older than 35 years and in smokers.
Progestin
Another method to treat menstrual irregularity is to take a hormone called progestin (eg, Provera) for 10 to 14 days every one to three months. This will induce a period in almost all women with PCOS, but it does not help with the cosmetic concerns (hirsutism and acne) and does not prevent pregnancy. It does reduce the risk of uterine cancer.
Hair treatments
Hair loss can be treated with medications in some situations, although medications are not usually as effective in women as they are in men. Other options include hair replacement and wigs.
Weight loss = #1 Treatment
Weight loss is the most effective approach for managing insulin abnormalities, irregular menses, and other problems of PCOS.
For example, many women with PCOS who lose 5 to 10 % of their body weight notice their periods become more regular. Weight loss can often be achieved with a program of diet and exercise.
There are a number of ways to treat obesity, whether it is associated with PCOS or not. These always include diet and exercise. In extreme cases, may also include: weight loss medications, and weight loss surgery.
Weight Management Tips:
We will often have newly-diagnosed PCOS pts meet with an experienced nutritionist to help guide her toward a healthy future.
- Choose nutritious, high-fiber carbohydrates instead of sugary or refined carbohydrates
- Balance carbohydrates with protein and healthy fats
- Eat small meals & snacks through the day instead of large meals
- Exercise regularly to help manage insulin levels and your weight
Weight loss surgery may be an option for severely obese women with PCOS. Significant amounts of weight can be lost after surgery, which can restore normal menstrual cycles, reduce high androgen levels and hirsutism, and reduce the risk of type 2 diabetes. However, the side effects of the procedure must be carefully considered against the effort to lose weight.
Metformin (Glucophage: "But I don't have diabetes!")
When indicated, I will consult with our medical endocrinologist, in order to begin and manage use of metformin to sensitize you to insulin.
Metformin (Glucophage) is medication that improves the effectiveness of insulin produced by the body. It was developed as a treatment for type 2 diabetes, but may be recommended for women with PCOS in selected situations.
- If a woman does not have regular menstrual cycles, the first-line treatment is a hormonal method of birth control, such as birth control pills. If the woman cannot take birth control pills, one alternative is to take metformin; a progestin is usually recommended, in addition to metformin, for six months or until menstrual cycles are regular.
- Metformin may help with weight loss. Although metformin is not a weight-loss drug, some studies have shown that women with PCOS who are on a low-calorie diet lose more weight when metformin is added.
- If metformin is used, it is essential that diet and exercise are also part of the recommended regimen because the weight that is lost in the early phase of metformin treatment may be regained over time.
- Metformin is not usually recommended for women with PCOS who have difficulty becoming pregnant, as there is a more effective option in clomiphene citrate.
- An expert group does not recommend metformin for women with PCOS who have excessive hair growth (hirsutism). Birth control pills alone, or in combination with an anti-androgen medication, seem to be the better option.
Top 10 Tips for Managing PCOS, (youngwomenshealth.org)
1. Eat a balanced diet. Your body needs carbohydrates, protein& fat.
2. Choose healthy carbs that are high in fiber and low in sugar.
3. Load up on vegetables and fruits. They are high in fiber and packed with vitamins and minerals.
4. Balance your carbohydrate foods with proteins and healthy fats.
5. Limit your portions when you are eating high–carbohydrate foods (especially ones that are low in fiber).
6. Eat small meals and healthy snacks during the day instead of 3 large meals.
7. Don’t forget to exercise! Good nutrition is important, but it isn’t enough. You also need to exercise regularly. Adding exercise or increasing the exercise you already do will help you manage your PCOS.
8. Don’t get frustrated if you don’t lose weight quickly or if you’ve tried to lose weight before and it didn’t work. Learning how to choose and balance your carbohydrates and doing regular exercise will help!
9. Stay positive! It can be very difficult to achieve visible results. Doing what’s right for your body IS doing something good, even if you don’t see a big change in your weight.
10. Talk to Dr. Malley about managing your PCOS. Most young women with PCOS need to take medication, even with good nutrition and exercise. If you have more questions about PCOS and nutrition, we will have you speak with a nutritionist who has experience in working with teens with PCOS.
Treatment of infertility
When the time comes and you are ready for pregnancy, it may take longer, but is absolutely within reach.
If tests determine that lack of ovulation is the cause of infertility, several treatment options are available. These treatments work best in women who are not obese.
The primary treatment for women who are unable to become pregnant and who have PCOS is weight loss. Even a modest amount of weight loss may allow the woman to begin ovulating normally. In addition, weight loss can improve the effectiveness of other infertility treatments.
Clomiphene: is a medication that stimulates the ovaries to release one or more eggs. It triggers ovulation in about 80% of women with PCOS, and about 50% of these women will become pregnant.
A few studies have shown that taking metformin in addition to clomiphene increases the rate of ovulation; while other studies have shown no benefit. It is not clear if metformin is safe during pregnancy; women who take metformin before pregnancy are usually advised to stop it once pregnancy is achieved.
If a woman does not ovulate or is unable to conceive with clomiphene, there are other several other options a reproductive endocrinologist (one of our close colleagues), can use to help you ovulate. Ovulation occurs in almost all women with PCOS who use gonadotropin therapy; approximately 60% of these women become pregnant.
[Edited from uptodate.com, Robert L Barbieri, MD, David A Ehrmann, MD, last updated Jan. 2010, and youngwomenshealth.org, 2010, and personal experience with PCOS patients.]
“I love to see a young girl go out and grab the world by the lapels. Life's a bitch. You've got to go out and kick ass.” ~ Maya Angelou
